By Your Pupils You'll Be Taught
The most remarkable teacher I ever had coached our high school football team. He didn't rely on histrionics to motivate his players; rather, he clearly described the task he wanted performed, demonstrated it unambiguously, and always explained why it needed to be done in a particular fashion. One day coach Duane Fisher astonished me in a private conversation by telling me how much teachers could learn from their students. He went on to explain some of the lessons he had learned by listening to students' complaints, suggestions, and simple insights. At that early age, it hadn't occurred to me that students could possibly know enough to benefit anyone. I still hadn't heard Anna Leonowens, the British school marm recruited as a private tutor for the Siamese royal family, sing in Rodgers and Hammerstein's The King and I, "If you become a teacher, by your pupils you'll be taught."
Coach Fisher's insight hit home recently when I spoke on the topic of Class II corrections in Santos, Brazil. During a break, after I had related my experience with the Herbst appliance, one of the participants told me in excellent English that he knew about the Herbst and had wanted to use it, but that his remote location in northern Brazil prevented him from obtaining the necessary materials. He explained how he had made a simple substitute from .032" stainless steel wire that would protrude the mandible much like a Herbst appliance.
Dr. Carlos Filho then showed me some photographs of his invention, and the simple but unmistakable elegance of the idea almost leapt off the page. I encouraged him to write the article that appears in this month's issue of JCO. I predict that Dr. Filho's concepts will impress many of you as well with their simplicity of design, flexibility, and ease of construction.
Dr. Filho explained, almost apologetically, that he didn't intend to replace the Herbst, but that "sometimes you have to hunt with cats if you don't have dogs". Necessity is definitely the mother of invention in the case of his Mandibular Protrusion Appliances. These aren't useless, Rube Goldberg apparatuses. They are practical appliances that any clinician can easily implement with a minimum of expense and frustration. I started using both types as soon as I returned from Brazil, and I can confirm their utility and, in particular, their greater comfort and patient acceptance. In fact, these appliances have become an important part of my Class II correction armamentarium.
Essentially, the MPA permits the orthodontist to plan treatment according to the principle that Reed Holdaway popularized in his Visualized Treatment Objective: "starting with the end in mind". By positioning the mandible for correct overbite, overjet, and midline at the beginning of treatment, the clinician can start with a template for dentoalveolar development and then build the occlusion around this end-of-treatment anterior guidance. This is the theory I've pursued with the Herbst appliance, and it has worked reasonably well over the past few years. However, the concept shows evidence of working even better and more naturally with the MPA, since one doesn't have to use occlusion-altering stainless steel crowns, large tubes and bars, or lingual arches. The teeth can move into natural positions unimpeded and--as with the Herbst appliance--en masse, rather than one tooth at a time as with many of the maxillary molar distalizing techniques.
While successful and predictable treatment of Class II malocclusions remains one of our biggest challenges, the MPA also addresses the serious problem of maxillary molar and mandibular incisor anchorage preservation. As you read Dr. Filho's article, you'll probably envision other uses for the MPA. Once we have a critical mass of users, I imagine we will have several clinical studies and objective appraisals of this new approach.
The German statesman and naturalist, Alexander von Humboldt, once said, "There are three stages in the popular attitude toward a great discovery: first, men doubt its existence; next, they deny its importance; and finally, they give the credit to someone else." Should Dr. Filho's ideas prove valuable, JCO will have at least presented the proper author.